Institute for Global Health, University College London, London, UK.
Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.
Lancet Infect Dis. 2018 Jan;18(1):85-94. doi: 10.1016/S1473-3099(17)30540-6. Epub 2017 Oct 17.
In the UK, HIV incidence among men who have sex with men (MSM) has remained high for several years, despite widespread use of antiretroviral therapy and high rates of virological suppression. Pre-exposure prophylaxis (PrEP) has been shown to be highly effective in preventing further infections in MSM, but its cost-effectiveness is uncertain.
In this modelling study and economic evaluation, we calibrated a dynamic, individual-based stochastic model, the HIV Synthesis Model, to multiple data sources (surveillance data provided by Public Health England and data from a large, nationally representative survey, Natsal-3) on HIV among MSM in the UK. We did a probabilistic sensitivity analysis (sampling 22 key parameters) along with a range of univariate sensitivity analyses to evaluate the introduction of a PrEP programme with sexual event-based use of emtricitabine and tenofovir for MSM who had condomless anal sexual intercourse in the previous 3 months, a negative HIV test at baseline, and a negative HIV test in the preceding year. The main model outcomes were the number of HIV infections, quality-adjusted life-years (QALYs), and costs.
Introduction of such a PrEP programme, with around 4000 MSM initiated on PrEP by the end of the first year and almost 40 000 by the end of the 15th year, would result in a total cost saving (£1·0 billion discounted), avert 25% of HIV infections (42% of which would be directly because of PrEP), and lead to a gain of 40 000 discounted QALYs over an 80-year time horizon. This result was particularly sensitive to the time horizon chosen, the cost of antiretroviral drugs (for treatment and PrEP), and the underlying trend in condomless sex.
This analysis suggests that the introduction of a PrEP programme for MSM in the UK is cost-effective and possibly cost-saving in the long term. A reduction in the cost of antiretroviral drugs (including the drugs used for PrEP) would substantially shorten the time for cost savings to be realised.
National Institute for Health Research.
在英国，男男性行为人群（MSM）中的艾滋病病毒发病率多年来一直居高不下，尽管广泛使用了抗逆转录病毒疗法和高比例的病毒学抑制。暴露前预防（PrEP）已被证明在预防 MSM 中的进一步感染方面非常有效，但它的成本效益尚不确定。
在这项建模研究和经济评估中，我们使用了一种动态的、基于个体的随机模型——HIV 综合模型，对英国 MSM 中 HIV 的多个数据来源（英国公共卫生署提供的监测数据和全国代表性调查 Natsal-3 的数据）进行了校准。我们进行了概率敏感性分析（对 22 个关键参数进行了抽样），并进行了一系列单变量敏感性分析，以评估在过去 3 个月内有无保护肛交、HIV 检测初筛阴性且前一年 HIV 检测阴性的 MSM 中，基于性事件使用恩曲他滨和替诺福韦的 PrEP 方案的引入情况。主要模型结果为 HIV 感染人数、质量调整生命年（QALYs）和成本。
引入这样的 PrEP 方案，第一年结束时有大约 4000 名 MSM 开始使用 PrEP，第 15 年结束时有近 40000 名 MSM 开始使用 PrEP，将导致总成本节省（贴现后 10 亿英镑），避免 25%的 HIV 感染（其中 42%直接归因于 PrEP），并在 80 年的时间内获得 40000 个贴现 QALYs。这一结果特别敏感于所选择的时间范围、抗逆转录病毒药物（用于治疗和 PrEP）的成本以及无保护性行为的基本趋势。
这项分析表明，在英国为 MSM 引入 PrEP 方案在长期内是具有成本效益的，甚至可能是节省成本的。抗逆转录病毒药物（包括用于 PrEP 的药物）成本的降低将大大缩短实现成本节约的时间。
英国国家健康研究所。
